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Major depression in late life with AIDS delusions
Letters to the Editor Letters to the Editor are invited for comment on a topic of current interest or on material published in GENERAL HOSPITAL PSYCHIATRY. Letters should be typed double-spaced and are subject to editing according to space limitations.
Major Depression AIDS Delusions
in Late Life with
A Case Report and Review
Introduction Since its recognition in 1981, the most frequent psychiatric syndromes associated with HIV infection have been dementia, depression, and anxiety. HIV seronegative patients with excessive concern about AIDS have also presented to mental health care systems and have been described by such terms as AIDS anxiety [l], AZDSparanoia [2], pseudo-AIDS [3], AIDS phobia [4], factitious AIDS [5], and AIDS hysteria [6]. Most of these reports have been associated with people who were at high risk of contracting AIDS. However, some cases have been described in patients who were at low risk for HIV infection [l]. At least one case report has been described in a geriatric patient with major depression and factitious AIDS syndrome 171. The following case report details the account of a 61-year-old female with major depression who insisted that her illness was caused by AIDS.
Case Ms. B was a 61-year-old,married,white femalewho presentedfor psychiatricevaluation10 months prior to admissionfollowinga second negative HIV antibody test. She expressed a delusional belief that despite negative antibody testing, she had acquired the HIV infection by kissing a fellow worker 4 years prior to her presentation. From the clinical presentation and symptom complex, the patient was felt to be suffering from a major depression. Outpatient therapy was offered, but she failed to follow through. Four months prior to her psychiatric hospital admission, the patient returned for further evaluation, following three additional HIV antibody tests. At this time, she recounted a history of increasing preoccupation with the brief encounter and increasing soGeneral Hospital Psychiatry 12, 207-209, 1990 0 1990 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
matic complaints, including musculoskeletal pain, stomach pains, lingering colds, sore throats, fatigue, and decreased mood, which she attributed to HIV infection. She noted a 20-lb weight loss, had disturbed appetite, increased sleep disturbance with frequent nocturnal and early morning awakenings, complaints of memory loss, confusion, and diarrhea. The patient began outpatient psychotherapy and was started on thiothixene and trazodone. Additional social history revealed a dysfunctional marriage of 43 years, whereby she felt emotionally extorted by her husband. Over the preceding 5 years, the husband developed a progressive dementia, blindness, diminished activities of daily living, increased irritability, and constant accusatory behavior. The patient failed to respond to outpatient therapy and was admitted to the hospital 10 months after her initial presentation. Upon admission, the patient was found to be have an isolated and wellcircumscribed delusion of having acquired HIV infection. In other spheres of her emotional life, she did not demonstrate delusional beliefs or behavioral patterns. Except for one daughter, she had successfully hidden her fear of having acquired HIV infection. Her routine work-up showed normal EEG, thyroid function studies, heavy metal urine toxic screen, and EKG. The patient’s RPR, B12, and folate levels, and ESR were all found to be negative. A head CT scan showed an incidental left posterior falx cerebri meningioma that the neurosurgeons thought to be insignificant and in no way related to her clinical presentation. The patient scored a 70 on the Beck Depression Rating Scale, a 27 out of 30 on the Geriatric Depression Scale, and a 30 out of 30 on the Folstein Mini Mental Status Exam. The patient was switched from trazodone to amitriptyline, 25 mg PO every night and thioridazine, 40 mg every night. Improvement did not occur, and because of the delusional quality of her depression and
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Letters to the Editor
her multiple somatic complaints, ECT was suggested as a treatment alternative. She agreed and received eight treatments. Her mood improved, as well as reduction in somatic complaints. Her delusional beliefs about HIV infection diminished. She remained skeptical of our insistence that she did not have the infection, nor that she transmitted the infection to other family members. After ECT, the patient was started on nortriptyline, 25 mg PO every night, and low-dose thiothixene, 2 mg PO every night. Upon discharge, the patient continued in supportive psychotherapy. Her preoccupation of the HIV infection remitted entirely, and she was able to devote appropriate attention to the care and management of her disabled husband as well as to feel the grief of her husbands illness and her dysfunctionalmarriage.
Discussion Previous case reports have described patients at high risk for HIV infection who present with claims that they have AIDS. In general, these patients fall into two categories: those suffering from major depression with obsessions or delusions about AIDS [2], or patients with a somatoform disorder with intense “AIDS anxiety” [l]. In cases where major depression has been the principal diagnosis, young patients responded to traditional antidepressant therapy [3,8]. But in the single case report of a geriatric patient presenting with major depression and AIDS delusion, ECT was found to be an effective treatment [7]. The case presented here and the previous case report [7] highlight the evidence that delusional beliefs are seen with greater frequency in late onset depression as opposed to depressive illness beginning in other age groups. Perhaps as many as 60% of all women and 50% of all men who have their index major depressive episode after age 60 will experience delusions [9-111. Ruegg and colleagues [ll] cite somatic and persecutory delusions, delusions of guilt and sin, obsessive rumination, and ideas of reference as frequent themes for elderly patients with depression. With the publicity received by the AIDS epidemic, and with its judgmental and guilt-ridden connotations, it is easy to understand how AIDS can become the symbol for such affects as guilt, shame, feelings of impotence, and powerlessness in a patient’s depression. As Frolkis points out, AIDS may be “a fortuitous pairing of personality and publicity,” and in the case of depression in late life, neurobiology. The positive response of these two patients to ECT confirms previous work that delusional depressives do not respond well to psy208
chosocial treatments or antidepressant treatment alone, but can be effectively treated by ECT [9]. Interestingly, young people with major depression and similar delusions about AIDS responded to conventional cyclic antidepressant treatment alone [2,8]. It’s unclear whether these patients were delusional about AIDS or whether they were exhibiting excessive concern about AIDS. Although the psychology about AIDS may be similar for both age groups, differences in response to treatment reinforces the evidence that late-life depression may have a more ominous biology. Recent evidence suggests that late-onset delusional depression may have an increased association with a variety of neurologic disorders, such as Binswanger’s disease, tumor, stroke, Alzheimer’s disease, and subfrontal white matter lesions [12]. These findings were not evident in the patient described here. Facing the challenges of HIV infection is a mandate for psychiatrists. These challenges not only include the care and management of the direct effect of the HIV infection on the central nervous system but also the psychologic sequelae of AIDS on patients during their illness. The publicity associated with the HIV infection has heightened the public’s awareness about HIV infection, and individuals prone to obsessional or delusional thinking could incorporate AIDS anxiety or pseudo-AIDS into their symptom profile. As demonstrated by this case, AIDS delusion is intergenerational, and as geriatric patients have an increased risk for delusional depression, AIDS-related fears and concerns may present as principal symptoms. Hence, establishing an accurate diagnosis of depression is crucial. In cases of late-life depression with AIDS delusions, as in any delusional depression, we suggest ECT as the principle treatment modality. Christopher C. Colenda III, M.D., M.P.H. Geriatric Psychiatry Program
Leslie Kryzanowski, M.D. Rochelle Klinger, M.D. Medical College of Virginia/ Virginia Commonwealth University Richmond, Virginia
References 1. Frolkis J: “AIDS Anxiety” new faces for old fears. Postgrad Med J 79:265-266, 268-270, 276-277, 1986 2. Alroe CJ, Franz P: “AIDS Paranoia.” Med J Aust 148369, 1988 3. Miller D, Greene J, Falmer R, Carroll G.: A “pseudo-
Letters to the Editor
4. 5. 6. 7. 8.
AIDS’ syndrome following fear of AIDS. Br J Psychiatry 146:550-551, 1985 Jacob K, John JK, Verghesse A, John T’J: AIDS phobia. Br J Psychiatry 150:412-413, 1987 Miller F, Weiden P, Sacks M, Wusniak J: Two cases of factitious acquired immune deficiency syndrome (letter). Am J Psychiatry 143:1483, 1986 Katz J: AIDS hysteria (letter). Can Med Assoc J 134:573-575, 1986 Shetty GC: Depressive illness with delusions of AIDS (letter). Am J Psychiatry 145:765, 1988 Jenicke M, Pato C.: Disabling fear of AIDS responsive to imipramine. Psychosomatics 27:143-144,1986
9. Chamey DS, Nelson JC: Delusional and nondelusional unipolar depression: Further evidence of distinctive subtypes. Am J Psychiatry 138:328-333,198l 10. Glassman AH, Roose SP: Delusional depression: A distinct clinical entity? Arch Gen Psychiatry 38:424427, 1981 11. Ruegg EG, Zisook S, Swerdlow NR: Depression in the aged: An overview. Psychiatr Clin North Am 11:83-99, 1988 12. Lesser IM, Miller BL, Golberg M, et al: Late onset psychosis and structural brain injury. New Research Abstracts, American Psychiatric Association Annual Meeting, Chicago, 1987
209
Major Depression AIDS Delusions
in Late Life with
A Case Report and Review
Introduction Since its recognition in 1981, the most frequent psychiatric syndromes associated with HIV infection have been dementia, depression, and anxiety. HIV seronegative patients with excessive concern about AIDS have also presented to mental health care systems and have been described by such terms as AIDS anxiety [l], AZDSparanoia [2], pseudo-AIDS [3], AIDS phobia [4], factitious AIDS [5], and AIDS hysteria [6]. Most of these reports have been associated with people who were at high risk of contracting AIDS. However, some cases have been described in patients who were at low risk for HIV infection [l]. At least one case report has been described in a geriatric patient with major depression and factitious AIDS syndrome 171. The following case report details the account of a 61-year-old female with major depression who insisted that her illness was caused by AIDS.
Case Ms. B was a 61-year-old,married,white femalewho presentedfor psychiatricevaluation10 months prior to admissionfollowinga second negative HIV antibody test. She expressed a delusional belief that despite negative antibody testing, she had acquired the HIV infection by kissing a fellow worker 4 years prior to her presentation. From the clinical presentation and symptom complex, the patient was felt to be suffering from a major depression. Outpatient therapy was offered, but she failed to follow through. Four months prior to her psychiatric hospital admission, the patient returned for further evaluation, following three additional HIV antibody tests. At this time, she recounted a history of increasing preoccupation with the brief encounter and increasing soGeneral Hospital Psychiatry 12, 207-209, 1990 0 1990 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
matic complaints, including musculoskeletal pain, stomach pains, lingering colds, sore throats, fatigue, and decreased mood, which she attributed to HIV infection. She noted a 20-lb weight loss, had disturbed appetite, increased sleep disturbance with frequent nocturnal and early morning awakenings, complaints of memory loss, confusion, and diarrhea. The patient began outpatient psychotherapy and was started on thiothixene and trazodone. Additional social history revealed a dysfunctional marriage of 43 years, whereby she felt emotionally extorted by her husband. Over the preceding 5 years, the husband developed a progressive dementia, blindness, diminished activities of daily living, increased irritability, and constant accusatory behavior. The patient failed to respond to outpatient therapy and was admitted to the hospital 10 months after her initial presentation. Upon admission, the patient was found to be have an isolated and wellcircumscribed delusion of having acquired HIV infection. In other spheres of her emotional life, she did not demonstrate delusional beliefs or behavioral patterns. Except for one daughter, she had successfully hidden her fear of having acquired HIV infection. Her routine work-up showed normal EEG, thyroid function studies, heavy metal urine toxic screen, and EKG. The patient’s RPR, B12, and folate levels, and ESR were all found to be negative. A head CT scan showed an incidental left posterior falx cerebri meningioma that the neurosurgeons thought to be insignificant and in no way related to her clinical presentation. The patient scored a 70 on the Beck Depression Rating Scale, a 27 out of 30 on the Geriatric Depression Scale, and a 30 out of 30 on the Folstein Mini Mental Status Exam. The patient was switched from trazodone to amitriptyline, 25 mg PO every night and thioridazine, 40 mg every night. Improvement did not occur, and because of the delusional quality of her depression and
207
ISSN 0163~K?43/90&3.50
Letters to the Editor
her multiple somatic complaints, ECT was suggested as a treatment alternative. She agreed and received eight treatments. Her mood improved, as well as reduction in somatic complaints. Her delusional beliefs about HIV infection diminished. She remained skeptical of our insistence that she did not have the infection, nor that she transmitted the infection to other family members. After ECT, the patient was started on nortriptyline, 25 mg PO every night, and low-dose thiothixene, 2 mg PO every night. Upon discharge, the patient continued in supportive psychotherapy. Her preoccupation of the HIV infection remitted entirely, and she was able to devote appropriate attention to the care and management of her disabled husband as well as to feel the grief of her husbands illness and her dysfunctionalmarriage.
Discussion Previous case reports have described patients at high risk for HIV infection who present with claims that they have AIDS. In general, these patients fall into two categories: those suffering from major depression with obsessions or delusions about AIDS [2], or patients with a somatoform disorder with intense “AIDS anxiety” [l]. In cases where major depression has been the principal diagnosis, young patients responded to traditional antidepressant therapy [3,8]. But in the single case report of a geriatric patient presenting with major depression and AIDS delusion, ECT was found to be an effective treatment [7]. The case presented here and the previous case report [7] highlight the evidence that delusional beliefs are seen with greater frequency in late onset depression as opposed to depressive illness beginning in other age groups. Perhaps as many as 60% of all women and 50% of all men who have their index major depressive episode after age 60 will experience delusions [9-111. Ruegg and colleagues [ll] cite somatic and persecutory delusions, delusions of guilt and sin, obsessive rumination, and ideas of reference as frequent themes for elderly patients with depression. With the publicity received by the AIDS epidemic, and with its judgmental and guilt-ridden connotations, it is easy to understand how AIDS can become the symbol for such affects as guilt, shame, feelings of impotence, and powerlessness in a patient’s depression. As Frolkis points out, AIDS may be “a fortuitous pairing of personality and publicity,” and in the case of depression in late life, neurobiology. The positive response of these two patients to ECT confirms previous work that delusional depressives do not respond well to psy208
chosocial treatments or antidepressant treatment alone, but can be effectively treated by ECT [9]. Interestingly, young people with major depression and similar delusions about AIDS responded to conventional cyclic antidepressant treatment alone [2,8]. It’s unclear whether these patients were delusional about AIDS or whether they were exhibiting excessive concern about AIDS. Although the psychology about AIDS may be similar for both age groups, differences in response to treatment reinforces the evidence that late-life depression may have a more ominous biology. Recent evidence suggests that late-onset delusional depression may have an increased association with a variety of neurologic disorders, such as Binswanger’s disease, tumor, stroke, Alzheimer’s disease, and subfrontal white matter lesions [12]. These findings were not evident in the patient described here. Facing the challenges of HIV infection is a mandate for psychiatrists. These challenges not only include the care and management of the direct effect of the HIV infection on the central nervous system but also the psychologic sequelae of AIDS on patients during their illness. The publicity associated with the HIV infection has heightened the public’s awareness about HIV infection, and individuals prone to obsessional or delusional thinking could incorporate AIDS anxiety or pseudo-AIDS into their symptom profile. As demonstrated by this case, AIDS delusion is intergenerational, and as geriatric patients have an increased risk for delusional depression, AIDS-related fears and concerns may present as principal symptoms. Hence, establishing an accurate diagnosis of depression is crucial. In cases of late-life depression with AIDS delusions, as in any delusional depression, we suggest ECT as the principle treatment modality. Christopher C. Colenda III, M.D., M.P.H. Geriatric Psychiatry Program
Leslie Kryzanowski, M.D. Rochelle Klinger, M.D. Medical College of Virginia/ Virginia Commonwealth University Richmond, Virginia
References 1. Frolkis J: “AIDS Anxiety” new faces for old fears. Postgrad Med J 79:265-266, 268-270, 276-277, 1986 2. Alroe CJ, Franz P: “AIDS Paranoia.” Med J Aust 148369, 1988 3. Miller D, Greene J, Falmer R, Carroll G.: A “pseudo-
Letters to the Editor
4. 5. 6. 7. 8.
AIDS’ syndrome following fear of AIDS. Br J Psychiatry 146:550-551, 1985 Jacob K, John JK, Verghesse A, John T’J: AIDS phobia. Br J Psychiatry 150:412-413, 1987 Miller F, Weiden P, Sacks M, Wusniak J: Two cases of factitious acquired immune deficiency syndrome (letter). Am J Psychiatry 143:1483, 1986 Katz J: AIDS hysteria (letter). Can Med Assoc J 134:573-575, 1986 Shetty GC: Depressive illness with delusions of AIDS (letter). Am J Psychiatry 145:765, 1988 Jenicke M, Pato C.: Disabling fear of AIDS responsive to imipramine. Psychosomatics 27:143-144,1986
9. Chamey DS, Nelson JC: Delusional and nondelusional unipolar depression: Further evidence of distinctive subtypes. Am J Psychiatry 138:328-333,198l 10. Glassman AH, Roose SP: Delusional depression: A distinct clinical entity? Arch Gen Psychiatry 38:424427, 1981 11. Ruegg EG, Zisook S, Swerdlow NR: Depression in the aged: An overview. Psychiatr Clin North Am 11:83-99, 1988 12. Lesser IM, Miller BL, Golberg M, et al: Late onset psychosis and structural brain injury. New Research Abstracts, American Psychiatric Association Annual Meeting, Chicago, 1987
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